Treatment of Nausea and

Vomiting in Pregnancy
(NVP)




John Campbell III MD
Trident Family Medicine Residency Program
Case Scenario
Mrs. G is a 27 y.o. G1 P0 who just
found out 2 wks. ago that she is
pregnant. She comes to your office
today because she has been feeling
sick to her stomach and vomited
several times in the last couple of
days. She has heard all the horror
stories of pregnancy and wants help
from you.
Next Slide
The case of Mrs. G
What do you tell her? (click on
answer)
A: This is very normal for pregnancy, just try not
to think about it.
B: This happens to most women early in their
pregnancy, well start with some diet adjustments
to help.
C: This is very common, we will start some
medications to help you.
Answer: B
70-80 % of pregnant women experience nausea and
vomiting during pregnancy (NVP). About 10% of the time
does it continue past the 1
st
trimester. Studies have shown
NVP can be very psychologically burdensome and needs to
be addressed, so A is not correct. There are several
medications that are safe and will be discussed later but are
only started initially if NVP is severe, so C is not correct.
Diet modifications are generally accepted as first-line
therapy for NVP, but the literature is inconclusive to the
benefits.

So what are the diet modifications?
NEXT
Diet Modifications:
Eat smaller, more frequent meals.
Avoid fatty, creamy foods which slow down gastric emptying.
Eat mainly carbohydrates which are bland such as potatoes,
pasta, rice, or soups including these.
Drink sports drink or bouillon in small sips for a total of 1- 1.5 L/
day to prevent dehydration. They tend to be better tolerated than
water.
Introduce crackers and peanut butter, or cheese in small amounts
as tolerated for protein.
Next, small amounts of baked chicken or fish can be introduced
as there are digested more easily.


So you tell her to try these and come back in about a week
if not improving.
NEXT
5 days later:
Mrs. G is back in your office. She has tried the
diet faithfully and is not having success. She is
frustrated, and her nausea and vomiting have
actually gotten worse. It is preventing her from
getting out and she is taking off from work
occasionally. She is distressed and wants
medication but is concerned about the effects on
her baby.
Is there anything you would do before
starting medications?
ANSWER
Before you give the Meds:
You would do a good physical exam, with
special concern for hydration status.

On physical exam, Mrs. G has
BP 100/60, P 80 while sitting, 95 when standing.
Urine dark yellow, specific gravity 1.025, small amt
ketones
2# weight loss from 1 week ago

How would you diagnose her at this point?

A. Hyperemesis Gravidarum
B. Nausea and vomiting of Pregnancy
C. Mild dehydration, normal pregnancy
D. None of these
Trick question!!
A. Hyperemesis gravidarum. This is a well-defined
diagnosis that wew ill discuss later. She does not fit criteria
at this point- we need to do more labs.
B. Nausea and vomiting of Pregnancy. This appears to be
what she has, but we need to do more testing to be sure it
is not more serious.
C. Mild dehydration, normal pregnancy. Mrs. G is mildly
dehydrated, but we do not know if the pregnancy is normal.
It is too early to make this decision.




Get some initial labs to rule out any other conditions that
could be causing nausea and vomiting. What would they
be and Why?
NEXT
WE NEED MORE INFORMATION!!
Labs to consider
Place mouse over each for more info
CBC
fasting serum glucose
Serum bHCG
Electrolytes
Liver enzymes
Amylase/Lipase
TSH
U/A
U/S of liver, gallbladder, or kidney based on symptoms
U/S of fetus

The labs that you draw depend on the clinical
situation. If afebrile with no abdominal pain, liver
enzymes, RUQ U/S, and amylase/lipase would not be
necessary.

Lab
Results
Lab results
CBC- normal
fasting serum glucose- 68
Serum bHCG- 40,000
Electrolytes- normal
Liver enzymes- not indicated
Amylase/Lipase- not indicated
TSH- normal
U/A- tr ketones
U/S of fetus- single IUP noted.
NEXT
So whats the diagnosis?
NVP
Hyperemesis
Gravidarum
This is NVP.

Hyperemesis gravidarum is a clinical
condition with generally agreed upon
symptoms.
Clinical Symptoms:
Persistent vomiting
Look for weight loss greater than 5% of
pre-pregnancy weight.
Dehydration (physical findings,
ketonuria)
Electrolyte abnormalities

NEXT
Rule-out hyperemesis gravidarum
for Mrs G.
Clinical Symptoms:
Persistent vomiting. She does not report this,
and seems to have a pattern of mainly AM
vomiting.
Look for weight loss greater than 5% of pre-
pregnancy weight. She has lost 2# in 1 week,
but prenatal assessment reveals height 56
and weight 145#.
Dehydration (physical findings, ketonuria).
She does have some physical findings of
dehydration including orthostasis, small
ketonuria.
Electrolyte abnormalities. BMP is completely
normal.

NEXT
You continue to consider her as having
NVP so you counsel her about possible
medications:
If mom is focused on primarily non-oral
medications, studies suggest that
acupressure to the P6 or Neiguan point on
the volar surface of the wrist, 3 finger-
breadths proximal to the wrist shows
benefit in nausea and vomiting. Several
OTC brands are Sea-Band, Reliefband
If she desires an oral medication,
then what would be her options?
ANSWER
1
st
line Therapy:
We want to combine efficacy with
safety.
Any of these could be first choices:
Vit. B6- 10-25 mg po TID
Ginger- 250 mg po QID
Acupressure
Doxylamine (Unisom OTC)- 25mg po
QD

Click for more first-line
drugs used for NVP.
First-line therapy for NVP
not associated with teratogenicity,
with proven effectiveness
Pyridoxine (Vit. B6). 10-25 mg TID. Few side effects. Preg.
Category: A
Ginger root. 250 mg QID. Few to no side effects.
Preg. Category: not rated
Antihistamines - more sedating. Preg. Category: B
Diphenhydramine(Benadryl) 25-50 mg po Q 4-8 hrs.
Meclizine (Antivert) 25 mg po Q 4-6 hrs.
Dimenhydrinate (Dramamine) 50-100 mg po Q 4-6 hrs.
Metoclopramide (Reglan) 5-10 mg po TID. Category: B
Doxylamine (Unisom) 25 mg po QD. Category: none, but
comprehensive review has shown safe.


Continue
Descript. of preg
drug categories
The case of Mrs. G
Mrs. G is sent home with a prescription
for Vit. B6 25 mg TID, and Ginger root
250 mg QID. She tries these faithfully and
has some benefit but she continues to
vomit regularly.

You have ruled out other conditions
so what would your 2
nd
line drugs be
for persistent vomiting?
ANSWER
2
nd
line Choices
selected from Category B + C Drugs
Anti-emetics
Phenergan: 12.5 to 25 mg po Q 4-6 hrs.
probably most popular
-Tigan: 250 mg po TID to QID
Anti-histamines
Benadryl (25-50 mg po Q 4-8 hrs),
Antivert, or Dramamine
Motility
Metoclopramide (Reglan)- 5-10 mg po TID
MORE OPTIONS
Second-line choices for NVP:
considered safe but clinically unproven,
Category B or C
Anti-emetics
Chlorpromazine (Thorazine): 10-25 mg po BID to TID.
Prochlorperazine (Compazine): 5-10 mg po TID to QID.
Promethazine (Phenergan): 12.5 to 25 mg po Q 4-6
hrs.
Trimethobenzamide (Tigan): 250 mg po TID to QID.
Ondansetron (Zofran): 8 mg po BID to TID.
Category B, very expensive, only studied with
hyperemesis
Steroids
Methylprednisolone (Medrol) 16 mg po TID then taper.
Could be a small teratogenic risk. Only studied with
hyperemesis.


Back to Case
Now what?
You send Mrs. G home again with
Phenergan 25 mg PR q 4-6 hrs to try to
help her with her symptoms. She calls in
reporting that Phenergan alleviates the
nausea and vomiting but it makes her so
tired she cant even function. This is
distressing her and her husband is upset
because his wife sleeps all the time.

What else could you give her?
ANSWER
End-of-the-line choice:
Zofran: 8 mg po BID to TID. This is
considered end-of-the-line due to
cost. Often it is not covered or only
partially covered by insurance. Its
use needs to be justified and should
be used only in hyperemesis
gravidarum.
NEXT
FDA categories of drugs in
pregnancy
A. Controlled studies in women fail to demonstrate a risk
to the fetus in the first trimester, and the possibility of
fetal harm appears remote.
B. Animal studies do not indicate a risk to the fetus; there
are no controlled human studies, or animal studies do
show an adverse effect on the fetus, but well-controlled
studies in pregnant women have failed to demonstrate a
risk to the fetus.
C. Studies have shown the drug to have animal
teratogenic or embryocidal effects, but no controlled
studies are available in women, or no studies are
available in either animals or women.
D. Positive evidence of human fetal risk exists, but
benefits in certain situations (e.g., life-threatening
situations or serious diseases for which safer drugs
cannot be used or are ineffective) may make use of the
drug acceptable despite its risks.
E. Studies in animals or humans have demonstrated fetal
abnormalities, or evidence demonstrates fetal risk based
on human experience, or both, and the risk clearly
outweighs any possible benefit.

Back
Mrs G. is very concerned that all this nausea and
vomiting is bad for her baby, so would you tell her?
A. NVP is always detrimental to the baby, and
she should be concerned about the pregnancy
and the babys health.
B. We do not fully understand the mechanism
behind NVP or the outcomes involving women
with this problem.
C. Uncomplicated NVP is associated with less
miscarriages, pre-term deliveries, stillbirths, fetal
low birth weight, growth retardation, and overall
mortality.
Answer: C
Many theories still exist as to the
pathophysiology of NVP, and there is no
conclusive etiology to date. Yet, there is
evidence that uncomplicated NVP is
associated with less miscarriages, pre-
term deliveries, stillbirths, fetal low birth
weight, growth retardation, and overall
mortality.

NEXT
Conclusion:
Mrs. G Finally found relief with Zofran. Her
insurance limited her to only 10 pills
because of the expense. She runs out of
the medication as her 1
st
trimester comes
to an end. She still has some minor
nausea which is able to be controlled with
Vit. B6. Her symptoms are mostly gone in
another two weeks. When you see her
again in the 2
nd
trimester they are totally
gone. She thanks you profusely and
continues to have a normal pregnancy.
To
review
Hyperemesis gravidarum is a clinical
condition with generally agreed upon
symptoms.
Clinical Symptoms:
Persistent vomiting
Look for weight loss greater than 5% of
pre-pregnancy weight.
Dehydration (physical findings,
ketonuria)
Electrolyte abnormalities

END
Lets Review
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9: 293-4.
Jewell D, and Young G. Interventions for nausea and vomiting in early
pregnancy (Cochrane Review). In: The Cochrane Library, Issue 3, 2004.
Chichester, UK: John Wiley & Sons, Ltd.
Koch K, Frissora C. Nausea and vomiting during pregnancy.
Gastroenterology Clinics 2003; 32(1): 201-34.
Magee L, Mazzotta P, and Koren G. Evidence-based review of safety and
effectiveness of pharmocologic therapy for nausea and vomiting of
pregnancy (NVP). Am J Obstet Gynecol 2002; 186(5 Suppl
Understanding): S256-61.
Niebyl J, and Goodwin T. Overview of nausea and vomiting of pregnancy
with an emphasis on vitamins and ginger. Am J Obstet Gynecol 2002;
186(5 Suppl Understanding): S253-5.
Quinlan J, Hill D. Nausea and vomiting of pregnancy. Am Fam Physician
2003; 68: 121-8.
Rosen T, et al. A randomized controlled trial of nerve stimulation for relief
of nausea and vomiting in pregnancy. Obstet Gynecol 2003; 102: 129-35.
Vutyavanich T, et al. Ginger for nausea and vomiting in pregnancy:
randomized, double-masked, placebo-controlled trial. Obstet Gynecol
2001; 97:577-82.